Unrecognized Sleep Difficulties and Caregiver Awareness at School Entry: A Population-Based Study of First-Grade Children.

Over the past decade, extraordinary efforts have focused on addressing the US opioid epidemic, which was fueled initially by prescription drugs and now by high-potency synthetic opioids, such as fentanyl. Treatment of opioid use disorder (OUD) with medications—buprenorphine, methadone, or long-acting naltrexone— improves outcomes, and buprenorphine and methadone reduce mortality. Behavioral treatments alone are markedly less effective. As a result, major efforts over the past decade have focused on increasing the reach of OUD medications. Any physician or advanced practice clinician can now prescribe buprenorphine. Providing treatment in primary care is critical to expanding access to care for people with OUD and improving OUD outcomes. Many questions remain about how to optimally increase buprenorphine treatment in primary care. In this issue of JAMA Internal Medicine, Rossom and colleagues report results of a trial that used clinical decision support (CDS) to increase primary care treatment of OUD. This adds to a small number of prior randomized controlled implementation trials testing approaches to increasing identification of OUD, initiation of buprenorphine, and OUD treatment retention in primary care. Many have assumed that screening with questionnaires or electronic health record (EHR) algorithms would increase identification of patients with OUD, as these strategies do for other behavioral health conditions. However, this may not be the case. Rossom et al, used EHR data to identify 1.5% of primary care patients with or at risk for OUD across 92 primary care clinics in 3 health systems. Of these patients, 9.5% were receiving OUD medications at baseline, and 59.4% had previously recognized OUD. The trial tested a CDS intervention that notified primary care teams that the patient was at increased risk of OUD and provided personalized recommendations. The CDS intervention did not increase new OUD diagnoses. This is consistent with a recent study evaluating brief screening for OUD in primary care, which also did not increase OUD diagnosis. We are unaware of any implementation study with a comparison group showing increased OUD diagnoses from substance use screening documented in the EHR. Studies validating screening questionnaires for identification of OUD have been conducted confidentially with results not shared with clinicians. Stigma or concerns that prescribed opioids could be withheld might make patients less likely to report high-risk opioid use if it will be documented in their medical record. One approach that appears to increase identification of patients needing OUD treatment is to make OUD treatment accessible and normative in primary care. A full-time nurse care manager (NCM) supporting diagnosis and OUD medication in primary care increased OUD diagnosis in another recent OUD medication implementation trial in primary care (PROUD trial).